Claims Examiner

Claims Examiner

Job Overview:

The Claims Examiner is responsible for investigating, evaluating, negotiating, and resolving property damage and bodily injury claims reported under company-issued insurance contracts. This role ensures claims are handled in accordance with policy provisions, applicable laws, and within documented authority. The examiner will communicate with insureds, claimants, and third parties while maintaining compliance with industry regulations and company policies.

Key Responsibilities:

Claim Investigation:

• Conduct thorough investigations of assigned claims, including gathering necessary information and documentation.
• Assign and direct independent adjusters as needed, and review public and other relevant records.
• Communicate with insureds, claimants, and involved parties to obtain required details and explain claims processes and resolution options.
• Ensure compliance with all claims-handling laws and regulations.
• At higher levels, engage and monitor defense counsel in consultation with management or work directly with internal legal counsel.

Coverage Analysis:

• Evaluate and determine the company’s obligations under applicable insurance contracts.
• Ensure proper compliance with jurisdictional insurance laws.
• Collaborate with the Legal Department on coverage determinations, compliance, and legal matters related to claims.

Loss Assessment:

• Analyze liability exposure of insureds and potential losses for claimants.
• Identify and report potential fraudulent claims to the Special Investigation Unit.
• Utilize decision-theory principles to assess and compare claim resolution scenarios.

Claim Reserving and Settlement:

• Establish and update appropriate case reserves based on available claim information.
• Review and approve or dispute invoices related to independent adjusters and other loss adjustment expenses.
• Maintain an organized and timely claim diary, ensuring claims are resolved efficiently and within assigned authority.
• Negotiate settlements within authority limits or submit recommendations for management approval.

Communication and Documentation:

• Maintain accurate records of all claim-related communications and activities.
• Document claim details, loss exposures, and resolution efforts in electronic claim files.
• Provide reports and updates on claim status to management and other stakeholders.

Licensing & Compliance:

• Obtain and maintain all required state adjuster licenses and certifications.
• Stay current on industry trends, insurance laws, and claims management best practices through continuing education and professional development.

Qualifications & Requirements:

Education:

• Bachelor’s degree in a related field or equivalent work experience.

Experience:

• Three or more years of relevant work experience in claims handling.

Preferred Knowledge & Certifications:

• Strong understanding of insurance contracts, coverage interpretations, and claims procedures.
• Knowledge of loss evaluation methods and claim resolution strategies.
• Industry-related coursework or certifications such as AIC (Associate in Claims) or CPCU (Chartered Property Casualty Underwriter) is preferred.

Required Skills & Abilities:

• Strong investigative, analytical, and negotiation skills.
• Effective case management, time management, and prioritization abilities.
• Excellent verbal and written communication skills, particularly in interactions with external parties.
• Ability to research and evaluate alternatives, make informed decisions, and provide recommendations.
• Maintain confidentiality and accuracy while working in a high-volume, deadline-driven environment.
• Ability to work collaboratively with internal teams and external stakeholders.

Company Culture & Employee Engagement:

Employees are encouraged to participate in Employee Resource Groups, which provide opportunities for networking, volunteering, social engagement, and professional development. Regular company-wide surveys ensure employee feedback is valued and considered in decision-making processes.